Provider Demographics
NPI:1124099353
Name:ENRIQUEZ, MARIETTA E (MD)
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:E
Last Name:ENRIQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1969
Mailing Address - Country:US
Mailing Address - Phone:502-774-4401
Mailing Address - Fax:502-772-8983
Practice Address - Street 1:3015 WILSON AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1969
Practice Address - Country:US
Practice Address - Phone:502-774-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22441208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK215580OtherMEDICARE
KY64224413Medicaid